Over the past couple of days I have been to two events that, despite occupying very different roles in the intellectual sphere, have both got me thinking more closely about language. Specifically, the language of health, illness and healthcare.
The first was a London Philosophy Club debate held on Tuesday evening on the ethics of psychiatric diagnosis. Peter Kinderman, a clinical psychologist and prominent critic of the disease model of mental disorder, gave an impassioned defence of the idea that the very term ‘diagnosis’ in psychiatry, along with terms such as ‘illness/disorder’ and ‘symptom’ invite a narrowly reductionist conceptualisation of mental health problems that distort and skew our very ability to think about them in broader social and psychological terms. He argued that the biological may indeed have a place in our thinking about and treatment of mental health problems, but that it should be subordinate to taking the problems of the person as primary. The proposal was not so much for a biopsychosocial model of mental disorder, as a call for dropping the term ‘disorder’ altogether, and replacing it with a description of ‘problems.’
The anti-reductionist critique is not new, and much of what he said contained echoes of Szasz’s rejection of mental illness as ‘problems in living’, but, if I understood him correctly, Peter was making a more subtle point about language rather than categories and causes. His idea was that the very language of illness and disorder was getting in the way of our ability to think clearly about the kinds of problems people face: it closes down possibilities for understanding the varied and often entirely understandable sources of distress. For example, a soldier returning from the front line experiences horrific flashbacks of his friends being injured or killed on the battlefield: is this symptomatic of a disorder? Is the solider ill? Or is he rather experiencing an extremely distressing situation, which of course warrants care and intervention, but that does not constitute a disorder? Conceptually, there is much to be unpacked in his argument, for example, it looks as though the ‘understandability’ of the trauma reaction is driving the intuition that it’s not disorder, which implicitly relies on the meaning/cause distinction dating back to Jaspers.
However, whatever the philosophical nuances of the debate, I was impressed by the linguistic (and self-consciously Wittgensteinian) argument that the language of disorder inherently constrains the capacity to think about problems in other ways: so long as the notion of mental ‘illness’ or mental ‘disorder’ persists, any attempts to humanise psychiatry and the treatment of mental health problems will be superficial at best.
This brings me to the second event: the King’s Fund annual conference. The King’s Fund is a health policy think tank, and I went to their conference yesterday in order to learn more about what they do, how the NHS is structured and managed, and what the prospects for the future of health and social care in this country are (particularly given the reforms occurring across the NHS at the moment). I have a longstanding interest in health policy but no direct experience, so it was somewhat daunting to be an outsider peering into the complex world of management, innovation and vast quantities of statistics for the day. The conference addressed the future of health and social care delivery, a term I have always found odd in the context of health and medical treatment. Repeated reference was made to health ‘outcomes’, managing ‘delivery’, ‘pathways’ to treatment, clinical audits and ‘indicators’, and engagement with ‘stakeholders’. As someone unfamiliar with this managerial vocabulary, it struck me as interesting that language of this type was so deeply embedded in the culture of the NHS.
Many of the presentations talked about the need to incorporate patient perspectives, to centre healthcare around the patient himself, and to make quality of care as important as quality of treatment. There are a number of patient advocacy groups, for example The Patient’s Association and Healthwatch England, that lobby and provide expert patient views on care and treatment in the NHS. Jeremy Hunt, the Secretary of State for Health, spoke about the recently uncovered abuses in the health and social care system, promising to prioritise care and support to staff to ensure that a culture of cruelty and contempt could not be allowed to flourish in parts of the system. One patient, Jonathon Hope, spoke movingly about his innumerable contacts with the healthcare system, having suffered kidney failure in his adolescence. Only once in his 30 or so years’ in and out of healthcare had he experienced decision-making that helped him feel supported and empowered, and he strongly advocated for the patient voice to play an absolutely central role in the healthcare system and in shared decision-making.
Few could disagree that these are laudable aims, and a healthcare system that sets out to place the patient at the centre of care could hardly be faulted. But with Peter Kinderman’s warnings about language constraining the possibilities of thought still resonating in my mind, I wondered just how possible this radical shift would be so long as the language of ‘service delivery’ is ingrained in the structure of the NHS. I wouldn’t tend to see a successful trip to the GP or A&E in terms of good health outcomes; I’d talk about feeling better, reassured, recovering, in less pain, being able to work and socialise again, and so on. I don’t think healthcare delivers a service to me in the way a plumber delivers a service when she fixes my leaking taps. This is, of course, a personal perspective but I’d be interested to learn if there’s much academic research in this area: on the language of healthcare, how patients perceive it, and whether they’re disenfranchised by a system that speaks an entirely different language. My own hunch would be that so long as those in authority (doctors, managers, industry, politicians) use this technical and managerial language, it will be impossible for all but the most engaged and expert patients to genuinely participate in decision-making, both about their own particular care and treatment, and about the way the NHS is structured run. The power will remain with those who understand and use the right kind of language.
If government and the powers that be in the NHS are serious about including patients in every step of their engagement and the care they receive, might it be time to reflect upon the language that is used to describe the healthcare system: not just to patients, but right across the board? For, as the argument from Kinderman suggests, if our thinking is constrained by particular conceptions of health, illness, outcomes and the model of service delivery, there are limits to how different (dare I say, innovative?) ideas about how to involve patients can possibly be formulated and developed.
All views are my own and do not reflect those of CHH or King’s College London